Effect of reusing suction catheters on the

occurrence of pneumonia in children

Maureen K. Scoble, RN, RM,a Beverley Copnell, BAppSc, RN, RSCN,a Anna Taylor, BN, RN,a
Sharon Kinney, MN, RN,b and Frank Shann, MB, BS, MD, FRACP,a,b Melbourne, Australia

OBJECTIVE: The purpose of this study was to determine whether disposable suction catheters can be
reused in the same patient for a 24-hour period without affecting the incidence of pneumonia.
DESIGN: The study design was a randomized controlled trial.
SETTING: The study was conducted in the pediatric intensive care unit of a tertiary pediatric center.
SAMPLE: Subjects included 486 children with an endotracheal tube in place.
OUTCOME MEASURES: The development of pneumonia, diagnosed with radiographic and clinical
evidence, was the measure. Cost analysis was also undertaken.
METHOD: Subjects in the study group (n = 241) were suctioned using the same catheter for a 24-hour
period. Those in the control group (n = 245) had a new catheter for each episode of suctioning.
RESULTS: Pneumonia developed in 14 members (5.71%) of the control group and in 12 members
(4.98%) of the study group, a difference of 0.7% (95% CI, 3.3% to 4.7%). Cost analysis indicated a
saving of Aust $4.14 per patient per day.
CONCLUSION: Reusing suction catheters for up to 24 hours is both safe and cost-effective.
(Heart Lung 2001;30:225-33.)

ndotracheal suctioning is one of the most frequently performed nursing tasks in intensive
care units (ICUs). Patients may require suctioning between 3 and 24 times a day. Consequently, suction catheters are the single biggest item of
expenditure in consumables in our pediatric ICU
(PICU). Budget constraints prompted us to investigate ways of reducing this expenditure. From anecdotal reports, we were aware that in some units disposable suction catheters are reused for multiple
episodes of suctioning. Although considerable cost
From the aRoyal Childrens Hospital, Melbourne, and the bUniversity of Melbourne.
Supported by funding from the Nursing Research Management
Group, Royal Childrens Hospital, Melbourne.
Reprint requests: M. K. Scoble, Paediatric Intensive Care Unit,
Royal Childrens Hospital, Flemington Rd, Parkville, Vic 3052, Australia.
Copyright 2001 by Mosby, Inc.
0147-9563/2001/$35.00 + 0 2/1/115519
doi:10.1067/mhl.2001.115519

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savings would result from this change in practice,

concerns were raised regarding its safety, and
many nurses were reluctant to implement the protocol. Because the effect of this practice on infection rates has not previously been investigated, we
conducted a randomized controlled trial comparing single use of suction catheters with 24-hour use.

LITERATURE REVIEW
Nosocomial pneumonia is a major concern in
ICUs, increasing mortality and morbidity in critically ill patients, prolonging the duration of hospitalization, and consequently increasing the cost of
treatment.1 The reported prevalence ranges from
7% in neonatal ICUs1 to 40% in some adult ICUs.2
Endotracheal intubation has been identified as the
biggest risk factor for nosocomial pneumonia
because it prevents closure of the glottis and
impairs natural defenses.1 Because the risk of
pneumonia in ventilated patients increases with
longer duration of intubation, it is suggested that

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infection rates are most appropriately expressed in

terms of infections per 1000 ventilator days.3,4 In
pediatric patients, rates have been reported at 5 to
6 infections per 1000 ventilator days.1,3 The most
common mode of infection in ventilated patients
appears to be aspiration of oropharyngeal or gastric
secretions.1,4 The role played by equipment is far
less clear. Colonization of the endotracheal tube
appears to occur almost immediately after it is
placed,5 but there is no evidence that colonization
alone, in the absence of other risk factors, leads to
infection.
Suctioning of the endotracheal tube has been
implicated in the development of nosocomial
pneumonia. Infection has been described as
resulting from mucosal trauma of the lower trachea
and carina, caused by deep suctioning.6,7 Dislodgement by a suction catheter of bacteria colonizing the endotracheal tube has been demonstrated to occur in in vitro experiments,8 but there
is no clinical evidence that this mechanism leads to
infection.1 Infection resulting from the introduction
of pathogens into the endotracheal tube by the
suction catheter is theoretically possible, and
many writers recommend using a sterile suctioning
technique as a precautionary measure.6,7,9-12 What
constitutes a sterile technique is open to interpretation, and a number of procedures have been recommended by different writers, such as wearing
sterile gloves10 and changing the catheter after
each pass.9,13 However, there appears to be no evidence base for these recommendations.4,12
Comparative studies of suctioning techniques
have been performed of closed system, in-line suctioning devices. Four randomized trials14-17 and 2
descriptive studies18,19 were found; each of the latter was comprised of 2 groups of patients studied a
year apart and compared closed system suctioning
(CSS) devices with a conventional open system. Of
the 6 studies, 1 compared measurements of bacteria on the catheter tips only,14 and 1 studied colonization of patients as well as infection.16 The rest
compared infection rates only. Ritz et al14 found no
difference in the contamination rate of catheters.
Deppe et al16 found an increase in colonization
rates with CSS, but no difference in infection rates.
Baker et al,19 Johnson et al,17 and Conrad et al15
likewise found no difference in infection rates
between the 2 groups, while Mumford18 found
infection rates to be lower in the CSS group,
although no statistical analysis was reported.
In a study of more than 500 patients, Kollef et
al20 compared the incidence of ventilator-acquired
pneumonia in patients whose CSS catheters were
changed daily with that of patients who received no
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Scoble et al

routine changes. In the latter group, catheters

remained in use for the duration of intubation or
until a change was indicated for reasons such as
mechanical failure or visible soiling. No differences
were found in the incidence of pneumonia between
the 2 groups.
The results of the preceding studies indicate
that repeatedly passing the same catheter into a
patients endotracheal tube does not influence the
development of pneumonia when the catheter is
part of a closed circuit. These studies were all conducted on adult patients, and we found no similar
research in children. Nor is there any literature
indicating whether these findings can be extrapolated to ordinary disposable suction catheters.
Although published guidelines recommend that
these catheters be used once only when employing
an open technique,4 this recommendation does
not appear to be research-based.

AIM
The aim of this study was to determine whether
ordinary disposable suction catheters could safely be reused for a 24-hour period. We tested the
hypothesis that the incidence of pneumonia
would not differ between children who were suctioned using 1 catheter for 24 hours and children
who were suctioned using a new catheter for each
episode.

METHODS
Sample and setting
The study was carried out between July 1995 and
May 1998 in the PICU of the Royal Childrens Hospital in Melbourne, Australia, a large metropolitan
tertiary referral hospital. The PICU has 13 beds and
admits approximately 1300 patients annually. The
age of patients admitted to the unit range from
newborn to 16 years, and neonates constitute
approximately 12% of all admissions. Preterm
infants are rarely admitted to the PICU. The severity of illness of the patient population has been
described in detail elsewhere.21
All children who were intubated in the unit or
who had an endotracheal tube in place on admission were entered into the study, with the following
exclusions:
1. children who had clinical and documented
evidence of lower respiratory tract infection
before entry into the study; that is, with a
clinical diagnosis of croup, pneumonia, or
bronchiolitis;
2. children who had been intubated for more
than 24 hours before admission;
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Table I
Number of patients excluded from analysis after randomization and reason for exclusion
Exclusion

Control group (n = 611*)

Study group (n = 588*)

Reason for exclusion

Intubated < 24 hours
ECMO
Lost to follow up
Previously entered into trial
LRTI at time of randomization
Patient had tracheostomy rather than ETT
Intubated >24 hours before admission
Incorrect catheter usage
Total exclusions

298
5
23
20
10
6
3
1
366

290
2
19
16
14
3
2
1
347

ECMO, Extracorporeal membrane oxygenation; LRTI, lower respiratory tract infection; ETT, endotracheal tube.
*Number randomized to the group.

Table II
Diagnostic categories of subjects
Category

Cardiac
Neonatal medical
Trauma
Neurologic (excluding traumatic brain injury)
Postoperative observation
Respiratory (excluding LRTI)
Other*

Control group

Study group

195
13
13
13
2
1
8

185
13
18
11
1
4
9

LRTI, Lower respiratory tract infection.

*Includes cellulitis (1), sepsis (8), hemopoietic disease (1), neoplasm (2), neuroblastoma (2), biliary atresia (1), post cardiorespiratory arrest (1), amoebaisis (1).

3. children who had previously been entered

into the study.
It was felt that children who were intubated for
less than 24 hours should not be analyzed because
pneumonia that developed within this time was
almost certainly incubating on admission and was
unlikely to be related to the suctioning procedure.22 Children requiring extracorporeal membrane oxygenation were also deemed unsuitable
for analysis because of the difficulty in interpreting
their chest radiographs. Hence, children in these 2
groups were subsequently excluded from the
analysis.
The required sample size was calculated to be
240 patients for each group, giving 80% power to
detect an increase from 5% to 11% in the incidence
of pneumonia ( = .05, 1-tailed test). A total of 1199
children was entered into the study, of which 713
were excluded from analysis. The majority (595) of
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these exclusions were a result of meeting the criteria described previously; however, 118 children
were withdrawn because of errors in the randomization or study procedures. The reasons for exclusion are listed in Table I. The resultant sample for
analysis was 486 patients, with 245 in the control
group and 241 in the study group.
The ages of the subjects ranged from 0 months
to 19 years, with a median of 3.25 months. Diagnostic categories on admission are shown in
Table II.

Procedures
Permission to conduct the study was granted by
the Hospitals Ethics in Human Research Committee. The Committee waived the requirement to
obtain written consent from parents or guardians
because both suctioning techniques were routinely
used in the PICU.
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Children were entered into the study after intubation or on admission if they were intubated outside our PICU. Patients were randomized to the
control group or the study group. Equal numbers in
the groups were ensured by using block randomization, with a block size of 4 subjects. The group
allocation was placed in a sequentially numbered,
sealed, opaque envelope, which was opened when
the patient was entered into the study.
In the control group, endotracheal suctioning
was performed using a new, sterile catheter for
each suctioning episode. A suctioning episode was
defined as a periodic clearance of the endotracheal
tube, passing the catheter as many times as
required; in general, clearance would require 2 to 3
passes. If it was necessary to clear the catheter
between passes, tap water from a metal container
kept at the bedside was suctioned through it. This
container was changed daily at 7 AM, as is routine
practice in the PICU. At the end of the episode, the
catheter was discarded into a paper bag hanging at
the patients bedside.
In the study group, the same catheter was used
for every episode of suctioning in a 24-hour period.
A new catheter was opened at 7 AM each day and
between suctioning episodes was stored in its
paper sheath and hung at the patients bedside.
This sheath was not removed during the 24-hour
period, so there was no possibility of using the
same catheter for more than 1 patient, and therefore no risk of cross infection between patients.
After each episode, tap water was suctioned
through these catheters to clear them, as well as
between passes if required, as with the control
group. The catheters were discarded in the same
manner as the catheters in the control group at the
end of the 24-hour period, or earlier if contaminated (for instance, by being dropped on the bed or
floor) or blocked.
Otherwise the procedure was identical in both
groups. Two nurses performed the procedure. One
nurse disconnected the endotracheal tube from the
ventilator or hand-ventilation circuit, supported the
tube during each pass of the catheter, and reconnected the tube after each pass, hand ventilating
between passes if required. The other nurse passed
the suction catheter, wearing a clean, unsterile
glove on the hand holding the catheter, and applying suction with the other, ungloved hand. Sterile
normal saline, stored in a tray at the patients bedside, was instilled into the endotracheal tube if the
nurse deemed it necessary. Both nurses washed
their hands before and after the procedure. Frequency of suctioning was determined by the nurse

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Scoble et al

caring for the patient. For all patients, humidification was provided by a water humidifier with a heated wire circuit. Ventilator circuits were changed
weekly, in accordance with the units protocol.
Patients remained in the study until pneumonia
developed, they were extubated (for any reason,
including death), or they had a tracheostomy performed. To allow for the clinical manifestation of
pneumonia incubating at the time of extubation,
patients who were extubated or underwent tracheostomy were followed for 24 hours after the
event (with the exception of patients who died). It
was considered that if pneumonia developed after
this time, it was unlikely to be ventilator-associated. Patients who were reintubated within the 24hour period remained in the study in the group to
which they were originally allocated; this event was
not recorded on the study data sheets.

OUTCOME MEASUREMENTS
The study outcome was development of pneumonia more than 24 hours after intubation and
within 24 hours of extubation. Age-specific World
Health Organization recommendations were adopted in defining pneumonia.23 The presence of all 3
of the following criteria were required for a positive
diagnosis of pneumonia to be made:24,25
1. an increase in the amount or thickness of
endotracheal secretions in intubated children, or the development of a respiratory
rate higher than normal for patients age following extubation25;
2. an increase in the immature to total neutrophil ratio in peripheral blood by at least
0.05 to more than 0.224;
3. the development of new infiltrates on chest
radiograph.25
The first criterion was assessed initially by the
bedside nurse, who recorded sputum properties or
respiratory rate (as appropriate) on the patient
chart. The study data collectors checked patient
charts daily. Chest radiographs were assessed by a
radiologist, per the routine in our unit. This person
was unaware of the group to which the patient was
assigned.
The time it took for pneumonia to develop was
also recorded. Time to infection was calculated
from the time of randomization to the date when it
was established that all of the criteria for pneumonia were present. Other data collected from patient
records included duration of intubation, duration
of ICU stay, sputum culture where available, administration of antibiotics, and whether the patient was
immunosuppressed. These data were collected by

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Table III
Patient characteristics
Category

Median age (range)

Duration of intubation*
Length of ICU stay*
Immunosuppression

Control group

Study group

2.89 mo (0-19 y)
56.18 h (16.01-197.09)
3.23 d (0.95-10.95)
2 subjects

3.32 mo (0-16 y)
61.87 h (14.94-256.22)
3.58 d (0.91-14.05)
5 subjects

*Geometric mean (95% CI).

Table IV
Summary of results
Result

Development of pneumonia (n)

Time to infection*
Cultures obtained (n)
Tracheal aspirate
Bronchial lavage
N/P aspirate
Sputum
Positive cultures
Organisms isolated (n)
None
Branhamalla catarrahalis
Escherichia coli
Candida albicans
Haemophilus influenzae
Adenovirus
Pseudomonas
Staphylococcus aureas
Acinetobacter
Parainfluenza virus type 3
Antibiotic use in uninfected children (n)

Control group

14 (5.71%)
3.26 d (0.34-31.63)
4
2
1
1
4
4
2
1
1
1
1
0
0
0
0
48 (21%)

Study group

12 (4.98%)
3.76 d (0.63-22.51)

NS
NS

5
2
1
0
7
1
1
0
1
2
0
2
2
2
1
62 (27%)

NS

NS, Not significant.

*Geometric mean (95% CI).

members of the research team and a number of

assistants. For patients in the study group, the
bedside nurses were asked to record whether they
discarded a catheter within the 24-hour period and
the reason for doing so.

Data analysis
Data were analyzed using the statistical packages Confidence Interval Analysis and Stata release
5.0. The effect of the control and study suctioning
techniques on the occurrence of pneumonia was
assessed by calculating the relative risk and

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absolute risk reduction and their 95% CIs. Logistic

regression was used to control for the effect of
duration of intubation, the only factor known to
influence pneumonia rates.1-3 The continuous variables were not normally distributed and their geometric means and 95% CIs are reported as measures of central tendency and dispersion. These
variables were compared by using a Student t test
on the geometric means. Categorical variables
were compared by using the Fisher exact test. P
values of less than .05 were accepted as statistically significant.

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RESULTS
Exclusions from the study are listed in Table I.
Diagnostic categories for the patients included in
this study are shown in Table II. Age, duration of
intubation, length of ICU stay, and presence of
immunosuppressant drugs are shown in Table III.
All other results are summarized in Table IV. Pneumonia was diagnosed in a total of 26 children
(5.35%): in 14 of the 245 patients (5.71%) in the control group, and in 12 of the 241 patients (4.98%) in
the study group. The relative risk was 0.87, with a
95% CI of 0.41 to 1.85. The absolute risk reduction
was 0.74% (95% CI, 3.26% to 4.73%, P = .84). Controlling for duration of intubation by using logistic
regression did not alter the effect of the group
assignation (odds ratio 0.662, P = .343).
The incidence of pneumonia was higher in children who had been intubated for a longer period
(odds ratio 4.1, P < .0005). Time for infection to
develop ranged from 1 to 83 days. In the control
group the geometric mean was 3.26 days (95% CI,
0.34 to 31.63), and in the study group 3.76 days (95%
CI, 0.63 to 22.51)(P = .74).
As indicated in Table IV, cultures from the respiratory tract were obtained in 16 of the 26 children in
whom pneumonia was diagnosed. The culture was
positive in 11 children, with more than 1 organism
being isolated in 1 child in the control group and 3
children in the study group. Of the 460 subjects
who showed no evidence of pneumonia, 48 (21%) of
the 231 children in the control group and 62 (27%)
of the children in the study group were treated with
antibiotics while intubated (P = .17). These figures
do not include children who received 4 doses of
cephazolin prophylactically after cardiac surgery.
Data concerning the frequency of, and reason
for, the suction catheter being discarded in the
study group were analyzed for the first 400 patients
entered into the study. Of these 400, 93 were randomized to the study group and included in the
analysis. The suction catheter was discarded
before the end of the 24-hour period in 42 of the 93
cases, and a total of 112 catheter discards were
reported. Reasons for discarding the catheter
included the following: contamination (31); blockage of the catheter (27); accidental opening of a
new catheter (25); and other (29). The category
other included finding the wrong size suction
catheter at the bedside, being unaware of the randomization, the need to perform respiratory investigations, and performing suction while transferring
the patient to another area of the hospital. This
subset of 93 patients had a total intubation time of
321.55 days, and 472 suction catheters were used

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Scoble et al

for them during that period. Therefore, each

catheter was used for a mean of 16.4 hours.
To analyse the cost of both suctioning techniques, we compared this subset of patients with
another subset of 93 sequential patients randomized to the control technique. The following costs
are expressed in Australian dollars. The cost of a
single suction catheter is $0.55; the total cost for
suction catheters for the patients randomized to
24-hour use was 472 $0.55, or $259.60. Hence, the
cost of this technique was $0.81 per patient day.
The 93 patients randomized to the control technique were intubated for a total of 341.2 days and
required 3069 catheters, at a cost of $1687.95, or
$4.95 per patient day. Hence, the study technique
resulted in a savings of Aust $4.14 per patient day,
an 84% reduction in cost.

DISCUSSION
We found no significant difference between the
control and study groups in the incidence of pneumonia. The 95% CIs for absolute risk reduction
(3.3% to 4.7%) indicate that it is unlikely that
reusing suction catheters increases the risk of
pneumonia by more than 3.3%. Because this potential increase represents the worst-case situation,
we believe it is not clinically significant. There was
also no difference between the groups in the time
taken for infection to develop. Hence, our findings
challenge the notion that endotracheal suctioning
should be a sterile rather than clean procedure.
While Tablan et al4 suggest using each catheter
only once if an open suctioning technique is
employed, this recommendation is classed as category II, which may be based on suggestive clinical
or epidemiologic studies or on a theoretical rationale. Our study provides evidence to challenge the
recommendation.
The practice of reusing disposable suction
catheters is similar in 1 respect to using closedcircuit systems, in that both techniques involve
passing the same catheter several times down the
endotracheal tube. The findings of our study are
consistent with the studies of closed-circuit systems in adults, which have demonstrated the safety of these systems,15-19 and that suggest that it is
unnecessary to change closed-system catheters
routinely.20 A more recent suggestion that closed
systems may actually reduce the risk of ventilatoracquired pneumonia (by reducing the frequency of
manipulation of the ventilator circuit) is, as yet,
unsupported by research.4,26 Furthermore, several
potential problems have been reported with the
use of closed systems. Nurses frequently report

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their inability to effectively remove secretions13,17,27,28 and the need for more frequent suction.28 It has been suggested that closed systems
may not be suitable for patients with thick secretions,13 and build up of secretions has been found
to lead to narrowing of the lumen of the endotracheal tube, with the potential for increased airway
resistance and increased work of breathing.29 Other
problems reported with the use of closed systems
include ineffective rinsing of the catheter with
backflow of the rinsing solution into the endotracheal tube and hand contamination from condensate spray when the irrigation port is opened,
resulting in nursing staff needing to wear gloves
and increasing the cost of the procedure.13 Hence,
reusing ordinary disposable suction catheters may
be a viable alternative to closed systems.
Another cause for concern with closed systems is
their cost. Routine changing of closed system
catheters every 24 hours is more expensive than
conventional open suctioning, during which 1
catheter is used for each episode.19,27 Kollef et al20
demonstrated a cost saving of US $837 in 258
patients by not routinely changing the CSS
catheters. The cost of this practice is likely to be
similar to, or slightly cheaper than, a conventional
open system using 1 disposable catheter per
episode. However, using 1 disposable catheter for
24 hours is the cheapest option by far.
We did not determine the period of time for
which a catheter may safely be reused. It was clear
that in many cases catheters were not used for the
24-hour period that was intended in the study
design. The average life of a catheter for a subset of
the study population was 16 hours, but we did not
collect data to indicate the minimum length of time
for which catheters were used. Neither did we
attempt to prolong the usage of catheters beyond
24 hours. Practical issues are as relevant as safety in
determining the length of time for which catheters
should be used.
The diagnosis of nosocomial pneumonia is difficult and has been the focus of several studies in
adults.30 While some researchers suggest the need
for invasive diagnostic testing by using bronchoscopic techniques,31 others have indicated that
clinical criteria have good diagnostic sensitivity
and correlate well with patient outcomes.20,32,33
There is no consensus on the use of nonbronchoscopic diagnostic tests.30 Many of the tests
described in these studies cannot be performed in
conjunction with smaller endotracheal tubes, and
no definitive method for diagnosing pneumonia in
the pediatric population has been identified. In

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determining diagnostic criteria for our study, we

were guided in part by the study design. Because
patients remained in the study until 24 hours after
extubation, diagnostic criteria that depended on
the presence of an endotracheal tube could not be
used. Hence, clinical signs provided the most reliable indicators, and we chose to follow the recommendations developed by the World Health Organization.23 The criteria we used are all nonspecific
when considered separately, but in combination
are highly suggestive of the presence of pneumonia.23-25
The infection rate in our study is, at approximately 5%, considerably lower than that reported in
the studies cited previously, in which pneumonia
rates were variously reported as around 15%,19,20
30%,16 40%,15 and 50%.17 This finding is not surprising because ventilator-associated pneumonia is
known to be less prevalent in children.1,3 However,
it is difficult to compare the infection rate found in
this study with those of other studies and other
institutions; the rate of 5% represents only the incidence in patients who were intubated for more
than 24 hours and not the incidence in all patients.
Furthermore, it does not take into account the
duration of intubation, which is short in our unit.21
As stated earlier, the most appropriate expression
of infection rates is generally agreed to be infections per 1000 ventilator days.1,3 Caution is therefore required in interpreting the infection rate
found in this study as a measure of the overall performance of our unit. We found that the incidence
of pneumonia increased with longer intubation
times, a finding that is well supported in the literature.1-3
One apparent weakness in the design of our
study is that we did not control for, or record, the
use of prophylactic antibiotics in cardiac patients. A
review of antibiotic prophylaxis suggests that it is
effective in preventing pneumonia in adults.34
However, the studies reviewed in this paper all
involved the administration of systemic antibiotics
for at least 3 days, in conjunction with topical
antibiotics. It is debatable whether the regimen in
use in our unit, which consists of 4 doses of intravenous cephazolin in isolation, would have a similar effect. However, because the number of cardiac
patients was similar in each group, we believe that
if this factor were of any importance it would have
affected patients in both groups equally.
One controversial aspect of the study relates to
the ethical and legal concerns raised by reusing
equipment that is labeled by the manufacturer as
single use. This issue has received considerable

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attention in the medical and allied health literature, mainly in relation to blood-borne infections
and the resterilizing of equipment that is intended to be disposable.35,36 Guidelines issued by the
National Health and Medical Research Council of
Australia37 relate specifically to these practices.
Our practice regarding suction catheters differs
significantly from those discussed in this literature; the catheters are not resterilized and are not
passed from patient to patient, hence the risk of
cross-contamination is not increased. No independent recommendations have been made that
relate to such practices. We suggest that the manufacturers use of the term single use in this
respect is imprecise, and that it would be more
appropriate for them to recommend single
patient use.
It was difficult to introduce the practice of
reusing suction catheters into our unit, and, in spite
of the results of this study, it continues to be
unpopular with some nurses. Our experience suggests that subjective impressions and ingrained
habits are difficult to overcome, which highlights
the problem of translating research findings into
practice.38,39

Limitations
Generalization of these results is limited
because our institution may not be representative.
Despite the high severity of illness, patients in our
unit (including patients in this study) had a short
intubation time, which is characteristic of our unit,
and this undoubtedly contributed to the low prevalence of pneumonia. Caution is therefore required
in generalizing our results to patients requiring
long-term ventilation. The patients in our study
generally had a relatively low risk of contracting
ventilator-associated pneumonia; clinicians may
find any increased risk less acceptable in patients
who are more vulnerable. Practical considerations
may limit the use of this technique in adults
because the larger volumes of secretions in these
patients may make blockage of catheters more
common.
The study required a high level of compliance
from the unit nursing staff in following the protocol.
Although we conducted an audit of a subset of
patients, it was difficult for the research team to
monitor the staffs willingness to comply throughout
the life of the study, and for the most part we had to
assume that patients received the management to
which they were allocated, and that data were
recorded accurately. We did observe a decrease in
compliance with documentation over time.

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Recommendations for further

research
More research into the influence of suctioning
technique on the occurrence of nosocomial pneumonia is required. We recommend duplication of
this study both in similar institutions and in other
settings with different types of patients. Further
research is warranted to determine the appropriate length of time for which a suction catheter may
be used.

CONCLUSION
This study investigated the practice of reusing
suction catheters in pediatric intensive care
patients for up to 24 hours. We found that the practice had no effect on either the rate of pneumonia or
the time taken to develop infection. We conclude
that this practice is both safe and cost effective.
We thank Ena Ahern, Dennis Kerr, Glenda Rolley,
Linda Savige, Sue Stevens, David Venables, and Cecilia White for their assistance with data collection and
the PICU nursing staff for their ongoing support.

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